Provider Demographics
NPI:1396272043
Name:DR VIDAL N LOPEZ MD PA
Entity type:Organization
Organization Name:DR VIDAL N LOPEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDAL
Authorized Official - Middle Name:N
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-480-5680
Mailing Address - Street 1:2682 SW 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2000
Mailing Address - Country:US
Mailing Address - Phone:305-480-5680
Mailing Address - Fax:305-480-5702
Practice Address - Street 1:2682 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2000
Practice Address - Country:US
Practice Address - Phone:305-480-5680
Practice Address - Fax:305-480-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4844101YM0800X
FLME140472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038015600Medicaid